Changes in the computed tomography (pixel) value of mandibular ramus bone and fixation screws after sagittal split ramus osteotomy

The purpose of this retrospective study was to evaluate the changes in computed tomography (CT) values of ramus bone and screws after sagittal split ramus osteotomy (SSRO) setback surgery. The subjects were 64 patients (128 sides) who underwent bilateral SSRO setback surgery. They were divided into six groups according to the fixation plate type used and the use or not of self-setting α-tricalcium phosphate (Biopex): group 1: titanium plate and screws; group 2: titanium plate and screws with Biopex; group 3: poly-l-lactic acid (PLLA) plate and screws; group 4: PLLA plate and screws with Biopex; group 5: uncalcined and unsintered hydroxyapatite particles and poly-l-lactic acid (uHA/PLLA) plate and screws; group 6: PLLA/uHA plate and screws with Biopex. CT values (pixel values) of the lateral cortex, medial cortex, osteotomy site, and screws were measured preoperatively, immediately after surgery, and 1 year postoperatively using horizontal CT images at the mandibular foramen taken parallel to the Frankfort horizontal plane. There were significant differences in the time-course change of pixel values for the lateral cortex (P<0.0001) and the osteotomy site (P<0.0001) among the six groups. This study suggests that the fixation plate type and use of bone alternative material may affect bone quality during the process of bone healing after SSRO.

Changes in occlusal function after orthognathic surgery in mandibular prognathism with and without asymmetry

This study aimed to evaluate the postoperative changes in masticatory function in patients with jaw deformities with or without asymmetry treated by orthognathic surgery. Thirty female patients who underwent a Le Fort I osteotomy with sagittal split ramus osteotomy (SSRO) were enrolled. The patients were divided into symmetry and asymmetry groups. The bite force, occlusal contact area, and bite force balance were measured before and at 1, 3, and 6 months and 1 year after surgery; these measurements were compared statistically within and between the two groups. In the symmetry group, there was a significant difference in the preoperative bite force and the 1 month postoperative bite force (P=0.0033). In the asymmetry group, the bite force before surgery was significantly different from that at 1 month (P=0.0375) and at 1 year (P=0.0353) after surgery. Significant differences in the bite force were also observed between the following time points: 1 month and 1 year (P=0.0003), 3 months and 1 year (P=0.0034), and 1 month and 6 months (P=0.0486). The occlusal contact area, bite force, and occlusal balance tended to change after Le Fort I osteotomy with SSRO, with a significantly improved bite force in patients with asymmetry before surgery.

Treatment of high-risk solid tumors of childhood with myeloablative chemotherapy and autologous stem cell transplantation

Sixteen consecutive stem cell transplantations (SCT) were performed after myeloablative chemotherapy in patients with high-risk solid tumors of childhood. Seven patients received autologous bone marrow transplantation (ABMT), seven received peripheral blood stem cell transplantation (PBSCT) and two received ABMT + PBSCT. The progression-free survival was similar in three types of transplants (57% ABMT, 43% PBSCT vs. 50% ABMT + PBSCT). The rate of relapse in site of distant organs was also similar (57% ABMT, 57% PBSCT vs. 50% ABMT + PBSCT). There was no statistically significant difference in the hematopoietic recovery time between each group. PBSCT group had a significantly fewer days of food intolerance and a lower morbidity than ABMT group. The disease-free survival was 71% for neuroblastoma, 50% for small round cell tumors and 25% for rhabdomyosarcoma. Post-SCT therapy for possible reinfused tumor cells should be mandatory to decrease the frequency of relapse.

Multifunctional Ferroic Nanocomposites

As trends towards miniaturized components and systems continue in many fields, there has been a rapid development in similarly scaled-down composites. In the electronics industry, these nanocomposites (and especially active nanocomposites based on ferroic elements) form a basis for many of the recent advances in both information and charge storage. While the overall properties of some of these composites can be explained as straightforward extrapolations from the bulk properties, in other instances the small size of the ferroic phase has important consequences on the macroscopic behavior of the composite. This paper reviews some of the recent developments in small-scale ferroic nanocomposites and details the relation between component size and the resultant properties.

Comparison of the postoperative bowel function between transanal endorectal pull-through and transabdominal pull-through for Hirschsprung's disease: a study of the feces excretion function using an RI-defecogram

PURPOSE

Herein, we compared the bowel function after a transabdominal and a transanal procedure for Hirschsprung's disease (HD) using the clinical score and a quantitative evaluation of the feces excretion function based on the findings of an RI-defecogram.

MATERIALS AND METHODS

The subjects included 35 patients with short segment aganglionosis. In the two groups with transabdominal Z-shaped anastomosis (open group) and transanal endorectal pull-through (TEPT) (transanal group), the postoperative bowel function were evaluated based on the clinical score. In the RI-defecogram study, a time-activity curve was drawn for the (99m)Tc remaining in the rectum on defecation. The feces excretion function was thus quantified, with the time until the (99m)Tc in the rectum became 50% as T0.5 and the time until 90% of the feces were excreted from the rectum as T0.9.

RESULTS

The clinical score could be evaluated in 9 cases in the open group and in 15 cases in the transanal group. No significant difference was observed in the total clinical score between the two groups, but the urge to defecate and the constipation scores in the subcategories were significantly lower in the open group. The defecogram was performed included seven cases in the open group and five cases in the transanal group. When an analysis of covariance of the two groups was conducted for the T0.5 and T0.9 values using the postoperative months as a covariate, there was a significantly negative slope, and moreover, there was a significant difference between the two groups.

CONCLUSIONS

The RI-defecogram showed that feces excretion time improves with the postoperative months in both the groups, but the transanal group has higher feces excretion function in the early postoperative period compared with the open group. We consider the RI-defecogram to therefore be a useful examination method for evaluating the feces excretion function.

Patent ductus arteriosus flow patterns in the treatment of congenital diaphragmatic hernia

BACKGROUND

Congenital diaphragmatic hernia (CDH) mortality still remains high, due to lung hypoplasia and persistent pulmonary hypertension of the neonate (PPHN). Effective management of PPHN and time of operation are quite important to the improvement of CDH treatment. In order to determine the optimal time for operation, we monitored PPHN with cardiac ultrasound.

METHODS

PPHN was assessed with three parameters: patent ductus arteriosus flow patterns (PDAFP), %left ventricular diameter at diastole, and left ventricular fraction of shortening (LVFS). Four patients with an antenatal diagnosis were treated under this protocol. Diaphragm repair was performed when PDAFP became left to right shunt dominant and the pre- and postoperative course was analyzed with regular chart reviews.

RESULTS

The alveolar-arterial oxygen difference levels of four patients were 590, 335, 613 and 530 mmHg, and operations were carried out when the patients were 2, 2, 3 and 2 days old, respectively. In three of the four patients (all except case 3) the PDAFP changed from right to left shunt dominant or bidirectional (BD), to left to right shunt dominant within 48 h. The %left ventricular diameter at diastole was relatively stable around the time of operation. The LVFS of all patients decreased after the operation. Only the LVFS of case 3 decreased temporarily to less than 30% (which indicates poor left ventricular function) but recovered. No patients needed extracorporeal membrane oxygenation support. All patients survived the procedure and were extubated. Case 3, who took 10 days to become left to right shunt dominant after the operation, needed home oxygenation therapy for 10 months.

CONCLUSIONS

PDAFP was a reliable marker of PPHN on a high-frequency oscillatory ventilator to determine the optimal time for the operation for CDH. The optimal time for operation is supposed to be the time when PDAFP become left to right shunt dominant.

Is high amplitude propagated contraction present after transanal endorectal pull-through for Hirschsprung's disease?

The transanal endorectal pull-through (TAEPT) procedure is now widely performed for Hirschsprung's disease (HD), however, the colorectal function after TAEPT has not yet been adequately assessed. We evaluated the postoperative clinical outcome and colorectal function based on lower colonic manometry after TAEPT. Twenty-one cases of HD underwent TAEPT from 1998 to 2005. We examined the clinical outcome based on the requirement of enemas/suppositories, the number of defecations per day, the severity of perianal erosion, and the incidence of enterocolitis requiring hospital stay. Using a three-channel Dentsleeve catheter and UPS-2020 measuring device, we performed postoperative colonic manometry at three locations: (1) the anal canal, (2) 5 cm proximal to the anal canal, and (3) 10 cm proximal to the anal canal, during defecation, and then we measured the appearance of high-amplitude contraction (HAC) (duration >/=10 s, amplitude >/=100 cmH(2)O). Four of 21 cases were treated with enemas/suppositories no longer than 1 year. The number of defecations decreased gradually from 4 to 5 per day in the early postoperative period, reaching 2 to 3 per day about 1 year postoperatively. Perianal erosion was noted in 3 of 21 cases but it disappeared within three postoperative years. Two cases had enterocolitis. Lower colon manometry was performed in eight cases. Manometry during defecation was successfully monitored in six cases. HAC occurred in five of six cases (83.3%). The clinical outcomes after TAEPT were satisfactory in almost all cases. These good outcomes were possibly due to the occurrence of HAC during defecation, though HAC did not fill the definition of high amplitude propagated contractions (HAPCs). The occurrence of HAC after TAEPT might be caused by keeping any damage to the mesenteric ascending cholinergic nerve to a minimum during surgery. Further long-term observations are still required to make an adequate assessment of such cases.

Changes in urinary level and configuration ratio of d-lactic acid in patients with short bowel syndrome

The present study showed that the D-lactic acid configuration ratio in the urine rose earlier than that in blood or the urinary or blood D-lactic acid levels upon disease onset, and that the D-lactic acid measurement in urine is more sensitive and useful than that in blood. As this result, a prediction of a D-lactic acidosis may be possible. To simplify the procedure for detecting D-lactic acid, we first showed a correlation between the D-lactic acid configuration ratio in urine and blood, indicating urine could be used. To separate the optical isomers of lactic acid, we simplified our previous procedure. For chiral recognition, we chose O-acetyl-(-)-menthylation and analyzed the samples under GC/MS by capillary gas chromatography on a DB-5 MS column. This procedure is less sensitive than the former method, but it is faster and simpler, requiring only one derivatization step. This method may be useful for predicting D-lactic acidosis in patients with short bowel syndrome.

Laparoscopic Repair of Late-presenting Bochdalek Hernia in 2 Infants

Laparoscopic repair was performed on 2 infants with late-presenting Bochdalek hernia. Intraoperatively, the entire small intestine was herniated in 1 case and the stomach, small intestine, and part of the colon and spleen were herniated in the other case. Laparoscopic repair of Bochdalek hernia was successfully completed in both the cases. On the basis of our experience, 4 points seem important in laparoscopic surgery for Bochdalek hernia: (1) avoiding damage to the spleen while reducing organs back into the abdominal cavity; (2) ensuring visualization of diaphragmatic defect after reducing the spleen and intestinal tract; (3) ensuring sufficient width to suture the dorsal side of the diaphragm; and (4) identifying intestinal malrotation. We believe that the fourth point represents an advantage of a laparoscopic approach, which seems superior to the thoracoscopic approach and could represent a useful therapy for Bochdalek hernia in infants and older patients.

Insulin responses to selective arterial calcium infusion under hyperinsulinemic euglycemic glucose clamps: case studies in adult nesidioblastosis and childhood insulinoma

Selective arterial calcium stimulation and hepatic venous sampling (ASVS) for insulin secretion is used as a diagnostic procedure in patients with insulinomas or adult nesidioblastosis. In some of those patients, severe hypoglycemia requiring urgent glucose administration occurs during the procedure. Such glucose administration, however, may affect the results and damage the validity of the test. We report two cases of hyperinsulinemic hypoglycemia, in which ASVS tests were successfully performed under hyperinsulinemic euglycemic glucose clamps. A 40-year-old male with nesidioblastosis developed continual severe hypoglycemia several years after a Billroth II-Braun gastrectomy, and continuous glucose infusion could not be stopped even during ASVS tests. A 9-year-old girl with an insulinoma that showed atypical hypovascularity on imaging examinations had ASVS tests under a glucose clamp for safety. Hyperinsulinemic (approximately 100 microU/ml) euglycemic (approximately 90 mg/dl) clamps were achieved by an artificial endocrine pancreas. The insulin analogue lispro was utilized for clamps and endogenous insulin was measured with an assay that does not cross-react with the analogue. Diagnostically significant responses (more than twofold) of insulin secretion were observed under hyperinsulinemic clamps in both cases. The use of the hyperinsulinemic glucose clamp technique during the ASVS test should be considered for maintaining the safety of some hypoglycemic patients.

Application of optical isomer analysis by diastereomer derivatization GC/MS to determine the condition of patients with short bowel syndrome

To establish a method for separating the optical isomers of lactic acid, we modified the derivatization steps in our procedure for urinary mass-screening for inborn errors of metabolism. For chiral recognition, we chose O-trifluoroacetyl-(-)-menthylation derivatization instead of our previous method, trimethylsilyl derivatization, and the samples were then analyzed under GC/MS by capillary gas chromatography on a DB-5MS column. This method can be used to follow-up the condition of a patient with short bowel syndrome and to prevent onset and/or seizure. d-Lactic acid was also isolated from the urine of healthy controls as one of the main peaks in the chromatogram.

Sexual problems in male patients older than 20 years with anorectal malformations

BACKGROUND/PURPOSE

The nervi erigentes in high- and intermediate-type male anorectal malformation (ARM) runs a relatively medial course and is vulnerable in sacro-perineal dissection. These types of ARM are also associated with a high frequency of sacral anomaly, and sexual problems may be expected. However, sexual function cannot be evaluated until after the individual passes puberty. Few reports have investigated the sexual status of pubescent males with ARM. The present study evaluated sexual problems in patients with high- and intermediate-type ARM.

METHODS

Sexual problems such as erectile dysfunction and ejaculatory incompetence were evaluated in 17 of 23 men aged more than 20 years who underwent operation for high- or intermediate-type ARM between September 1974 and January 2005.

RESULTS

Erection angle was normal in 9 patients (52.9%), mild in 6 patients (35.3%), and dysfunctional in 2 patients (11.8%). Ejaculatory function was normal in 10 patients (58.8%), with ejaculatory incompetence in 5 patients (29.4%) and retrograde ejaculation in 2 patients (11.8%). Either erectile or ejaculatory dysfunction was present in 5 patients (29.4%), whereas both were present in 2 patients (11.8%). Sexual problems were identified in 7 patients (41.2%), with sacral anomalies in 5 (71.4%) of these 7 patients.

CONCLUSIONS

Sexual problems such as erectile and ejaculatory dysfunction are common in patients with high- or intermediate-type ARM. Patients with sexual distress require persistent follow-up and continuous counselling to support their sexual problems.

Usefulness of endoscopic marking for determining the location of transanal endorectal pull-through in the treatment of Hirschsprung's disease

In the treatment of Hirschsprung's disease, transanal endorectal pull-through (TEPT) is being performed without laparoscopic assistance or laparotomy for short-segment aganglionosis. Preoperative ascertainment of the extent of aganglionosis is required, as this affects the planning for TEPT. The present study investigated the usefulness of preoperative endoscopic marking as an intraoperative marker of the location of pull-through. Since 1998, we have performed TEPT using a prolapsing technique for the treatment of Hirschsprung's disease. Subjects comprised 17 patients with short-segment aganglionosis and 2 patients with long-segment aganglionosis in whom endoscopic marking was performed preoperatively. Median age at time of surgery was 2.7 months. The relationship between pathologic findings at the marked area and location of actual pull-through was investigated. For endoscopic marking, each patient was sedated using intravenous ketamine hydrochloride. The junction between normal bowel with peristalsis and aganglionic bowel without peristalsis ("shorebreak" finding) was marked by either tattooing or clipping. Normal ganglion cells were seen in the marked area of 14 patients, and pull-through was performed at the marked area in each of these patients. In three patients, ganglion cells existed in the marked area, but the number of ganglion cells was considered insufficient. Additional frozen sections were thus prepared to ascertain the area with normal ganglion cells, showing that normal ganglion cells were seen 1, 3 or 5 cm proximal to the marked area. In one patient, no ganglion cells were seen in the marked area, but were present 5 cm proximal to the marked area. In the remaining one patient, normal ganglion cells were seen 7 cm distal to the marked area. Pathologic findings revealed ganglion cells at the shorebreak finding in 17 of the 19 patients (89.5%), suggesting that this junction basically matches the distribution of ganglion cells. Endoscopic marking of the junction is very useful for determining the tip of pull-through.

Large cell calcifying Sertoli cell tumor of the testis: Comparative immunohistochemical study with Leydig cell tumor

Large cell calcifying Sertoli cell tumor is a rare type of testicular tumor. Reported herein is a Japanese patient with this tumor not associated with Carney's complex. An 11-year-old boy was admitted to hospital because of left testicular enlargement, and radical orchiectomy was performed. Macroscopically, the tumor was well circumscribed and had a maximum diameter of approximately 2 cm. The cut surface showed a yellow-white solid mass. Histologically, the tumor was composed of large neoplastic cells with abundant eosinophilic cytoplasm with a tubular, trabecular, and solid arrangement and loose myxoid stroma with irregularly shaped calcification. Immunohistochemically, the tumor cells were positive for vimentin, S-100 protein, calretinin, inhibin-alpha, melan-A, and CD10, and type IV collagen and laminin were observed in the extracellular matrix around the tumor cells. The distributions of melan-A, CD10, and mitochondria were characteristically patchy; in contrast, they were diffusely distributed in the cytoplasm in a control case of Leydig cell tumor. The differences in immunostaining patterns for melan-A, CD10, and mitochondria as well as positivity for S-100 protein-beta might be useful diagnostic hallmarks of large cell calcifying Sertoli cell tumor for discrimination from Leydig cell tumor.

Monitoring method for pre- and post-liver transplantation in patients with primary hyperoxaluria type I

Differential diagnosis of primary hyperoxaluria type I (PH1) may become difficult once end-stage renal failure and anuria have occurred. Here we describe a rapid and sensitive method to simultaneously quantify glycolate and oxalate in plasma using a stable isotope dilution and gas chromatography-mass spectrometry. The results are provided within 2 h. The linearity of the method was validated up to 200 micromol/l of these compounds and the inter-assay precision for glycolate and oxalate was 2.4 and 2.6%, respectively (n=5), when the control plasma was spiked with 50 micromol/l of glycolate and oxalate. For healthy subjects, 1.0 ml of plasma was required and 0.1 ml for the PH1 patients. Using this method, plasma levels in non-PH1 patients under hemodialysis and in healthy subjects were determined. This method proved to be useful when used for differential diagnosis of PH1 and for monitoring the plasma levels of glycolate and oxalate in two PH1 patients before and after dialysis and liver transplantation. Plasma glycolate in these patients was dramatically decreased after liver transplantation, but plasma oxalate decreased more slowly due to remobilization of the calcium oxalate stores deposited throughout the body.

Maternal cell traffic bounds for immune modulation: tracking maternal H-2 alleles in spleens of baby mice by DNA fingerprinting

We have previously reported that the immunization of pregnant mice with T-dependent antigens successfully induced suppression of the antigen-specific plaque-forming cell (PFC) response to the relevant antigens in the offspring. This suppression was not caused by the administered antigens, the antibodies produced by the pregnant mother, or lactational transfer, but was dependent on the presence of the intact maternal T cells. It was major histocompatibility complex (MHC)-restricted manner tolerance, which continued for at least one-sixth of the murine life. Traditionally, the placenta acts as a natural barrier, not allowing the cells to pass through. However, the results presented strongly suggested that maternal T cells pass through the placenta and subsequently induce tolerance. In this present study, we attempted to substantiate the presence of maternal cells in the fetal circulation through the use of molecular techniques. We found that a highly polymorphic microsatellite sequence within the class II Eb gene of the H-2 complex is useful for the molecular detection of various H-2 alleles. DNA polymorphic analysis was used for tracking maternal H-2 alleles in the spleens of baby mice. The main procedure involved polymerase chain reaction amplification and restriction fragment length polymorphism analysis of the DNA sequence encompassing the H-2-specific microsatellite from the genomic DNA of baby mice. The results indicated that maternal T cells of immunized pregnant mice cross the placenta into the fetus, eventually inducing antigen-specific immunological tolerance in the offspring.

Serum osteoprotegerin/osteoclastogenesis-inhibitory factor during pregnancy and lactation and the relationship with calcium-regulating hormones and bone turnover markers

Pregnancy and lactation induce dynamic changes in maternal bone and calcium metabolism. A novel cytokine termed osteoprotegerin (OPG)/osteoclastogenesis-inhibitory factor (OCIF) was recently isolated; this cytokine inhibits osteoclast maturation. To define the effects of pregnancy and lactation on circulating OPG/OCIF in mothers, we studied the changes in the levels of OPG/ OCIF as well as those of calcium-regulating hormones and biochemical markers of bone turnover in the maternal circulation during pregnancy (at 8-11 weeks, at 22-30 weeks, at 35-36 weeks and immediately before delivery) and lactation (at 4 days and at 1 month postpartum). Serum intact parathyroid hormone levels did not change and were almost within the normal range in this period. In contrast, serum 1,25-dihydroxyvitamin D levels increased with gestational age and were above the normal range during pregnancy. After delivery, they fell rapidly and significantly (P<0.01) to the normal range. The levels of serum bone-specific alkaline phosphatase, one of the markers of bone formation, increased with gestational age. After delivery, these levels were further increased at 1 month postpartum. The levels at 1 month postpartum were significantly higher than those at 8-11 and 22-30 weeks of pregnancy (P<0.01 and P<0.05 respectively). The levels of serum C-terminal telopeptides of type I collagen, one of the markers of bone resorption, did not change during pregnancy. After delivery, they rapidly and significantly (P<0.01) rose at 4 days postpartum, and had then fallen by 1 month postpartum. Circulating OPG/OCIF levels gradually increased with gestational age and significantly (P<0.01) increased immediately before delivery to 1.40+/-0.53 ng/ml (means+/-S.D.) compared with those in the non-pregnant, non-lactating controls (0.58+/-0.11 ng/ml). After delivery, they fell rapidly to 0.87+/-0.27 ng/ml at 4 days postpartum and had fallen further by 1 month postpartum. These results suggest that the fall in OPG/OCIF levels may be partially connected with the marked acceleration of bone resorption after delivery.

Molecular monitoring of bleomycin-induced pulmonary fibrosis by cDNA microarray-based gene expression profiling

Pulmonary fibrosis is a progressive disorder whose molecular pathology is poorly understood. Here we developed an in-house cDNA microarray ("lung chip") originating from a lung-normalized cDNA library. By using this lung chip, we analyzed global gene expression in a murine model of bleomycin-induced fibrosis and selected 82 genes that differed by more than twofold intensity in at least one pairwise comparison with controls. Cluster analysis of these selected genes showed that the expression of genes associated with inflammation reached maximum levels at 5 days after bleomycin administration, while genes involved in the development of fibrosis increased gradually up to 14 days after bleomycin treatment. These changes in gene expression signature were well correlated with observed histopathological changes. The results show that microarray analysis of animal disease models is a powerful approach to understanding the gene expression programs that underlie these disorders.

Various scoring systems evaluating histologic features of chronic hepatitis C treated with interferon

Various scoring systems for chronic hepatitis have been proposed; however, there is no standard scoring system for studies of interferon (IFN) therapy in patients with chronic hepatitis C. The aims of this study were to determine the most useful system reflecting histologic changes in biopsy specimens from complete responders and predicting the efficacy of IFN therapy. Patients with chronic hepatitis C were administered IFN-alpha for 6 months. Forty-six patients were included in this study and categorized as complete responders (n = 15), partial responders (n = 24), and nonresponders (n = 7) according to viral and biochemical responses to the therapy. Biopsy specimens obtained from each patient before and after treatment were evaluated under 3 different systems: Histological Activity Index (HAI), modified HAI, and Scheuer classification. Complete responders showed considerable improvement in both grade and stage on the modified HAI and Scheuer classifications. On the HAI, a considerable improvement was observed in grade but not in stage. No significant change was observed in partial responders or nonresponders on any system. Prediction of complete response was not possible under any system, but the pretreatment score reflecting piecemeal necrosis on any 1 of the 3 classifications and the fibrosis score on Scheuer classification were predictors of nonresponse. The modified HAI system and Scheuer classification were amply useful in evaluating histologic changes in complete responders. Scores higher than 4 of the categories reflecting piecemeal necrosis on any system and fibrosis scores of 3 or 4 on Scheuer classification predicted nonresponse to IFN therapy.

Autopsy case of alcoholic hepatitis and cirrhosis treated with corticosteroids and affected by Pneumocystis carinii and cytomegalovirus pneumonia

A case of the very early phase of Pneumocystis carinii pneumonia in a human immunodeficiency virus (HIV)-negative man with alcoholic hepatitis and cirrhosis treated with steroids is presented. A 40-year-old man with a 10-year history of alcohol abuse was admitted to hospital with jaundice, fever and macrohematuria. Laboratory examinations revealed neutrophilic leukocytosis and a serum bilirubin level of 13.9 mg/dL. The serum bilirubin level rose to 28.5 mg/dL over 1 month. Prednisolone administered orally for 10 days produced a slight improvement in the jaundice and fever. After an interval of a week, it was resumed and maintained for 22 days (total dose, 1555 mg) until the patient died of a massive hemorrhage from ruptured vessels of a gastric ulcer. An autopsy disclosed P. carinii pneumonia in the lower lobe of the left lung, cytomegalovirus infection in both lungs and the esophagus, and esophageal candidiasis. To our knowledge, this is the first report of P. carinii pneumonia together with cytomegalovirus infection in an HIV-negative alcoholic patient. The present case suggests that a rare opportunistic infection such as P. carinii pneumonia might be caused by treating cirrhosis and alcoholic hepatitis with corticosteroids, even if only for a relatively short period.

[Complications of stress echocardiography]

BACKGROUND

Stress echocardiography is an established clinical testing method and is accurate for the detection of coronary artery disease. Despite its widespread use, the safety of stress echocardiography has not been sufficiently documented in Japanese laboratories.

OBJECTIVES

The feasibility, safety, complications and side effects of stress echocardiography were assessed for detecting myocardial ischemia in patients with suspected coronary artery disease.

METHODS

1,866 patients who underwent dobutamine echocardiography(n = 897), exercise echocardiography(n = 722), and dipyridamole echocardiography(n = 247) were prospectively studied from November 1990 to April 2000. Dobutamine was administered intravenously at 5, 10, 20, 30, 40 micrograms/kg/min in 3-minute intervals. Exercise echocardiography used the supine ergometer, starting at 50 W and increasing gradually by 25 W at 3-minute intervals to the maximum of 150 W. Dipyridamole was administered intravenously at 0.14 mg/kg/min for 4 min. After a 4-minute observation period, the drug was re-administered at the same dose for 2 min.

RESULTS

The most common side effects under each stress were ventricular premature beats in 34.1% (dobutamine echocardiography), ventricular premature beats in 14.4%(exercise), and headache in 24.3% (dipyridamole). Serious side effects occurred in one patient(0.05%). The case of acute myocardial infarction was caused by dipyridamole echocardiography, and the patient needed emergency coronary angioplasty. Seven patients needed other drug therapy for nonsustained ventricular tachycardia(one), paroxysmal supraventricular tachycardia(two), sinus bradycardia(three), and bronchial asthma(one). There was no incidence of death, shock, or ventricular fibrillation, sustained ventricular tachycardia or other conditions requiring inpatient observation during stress echocardiography.

CONCLUSIONS

Stress echocardiography is a reasonable, safe method for determining myocardial ischemia, but may be associated with minor, self-limiting side effects.

Effect of PPAR activators on cytokine-stimulated cyclooxygenase-2 expression in human colorectal carcinoma cells

Cyclooxygenase-2 (COX-2) expression is up-regulated in colorectal cancer tissue. Peroxisome proliferator-activated receptors (PPARs) are expressed in human colorectal tissue and activation of PPARs can alter COX-2 expression. In macrophages, activation of PPARs down-regulates COX-2 expression. We examined the effect of PPARalpha and PPARgamma ligands on untreated and TNF-alpha-induced COX-2 expression in the human colorectal epithelial cell line HT-29. The expression of PPARalpha and PPARgamma was confirmed in these cells. TNF-alpha, an inflammatory cytokine, increased COX-2 expression via the NFkappaB pathway. In the absence of TNF-alpha, WY14643 (PPARalpha activator) caused an increase, while BRL49653 (PPARgamma activator) did not alter COX-2 expression. When HT-29 cells were incubated with TNF-alpha and WY14643, a further increase in COX-2 expression was detected. Incubation with TNF-alpha and BRL49653 caused an additional twofold increase in COX-2 expression. Our results suggest that both PPARalpha signaling and TNF-alpha signaling increase COX-2 expression by independent pathways, while PPARgamma stimulates COX-2 expression by up-regulation of the TNF-alpha pathway.

Hyperventilation and cold-pressor stress echocardiography for noninvasive diagnosis of coronary artery spasm

We report the usefulness of 2-dimensional echocardiography during the cold-pressor test immediately after hyperventilation for noninvasive diagnosis of coronary vasospasm in 43 patients with suspected vasospastic angina. The stress test consisted of hyperventilation for 6 minutes, followed by cold water pressor stress for 2 minutes under continuous electrocardiographic and echocardiographic monitoring. Coronary angiography with an intracoronary injection of acetylcholine was performed within 2 weeks after the stress test. Coronary spasm was observed in 33 patients by angiography. Multivessel spasm was diagnosed in 26 patients by stress echocardiography and in 23 patients by angiography. The stress-induced wall motion abnormalities occurred earlier than the ST-segment changes and chest pain. The wall motion abnormalities shown on the echocardiogram correlated well with the vascular territories of the coronary artery that had the spasm. The sensitivity, specificity, and diagnostic accuracy of hyperventilation and cold-pressor stress echocardiography for detecting vasospastic angina against coronary angiography with an intracoronary injection of acetylcholine were 91%, 90%, and 91%, respectively. However, the sensitivity, specificity, and diagnostic accuracy of hyperventilation and cold-pressor stress electrocardiography for detecting vasospastic angina were 48%, 100%, and 60%, respectively. No major side effects were observed during or after the stress test. Echocardiographic monitoring during the stress test detected spasm unaccompanied by either ST- segment changes or chest pain and revealed the location of multivessel coronary spasm. Hyperventilation and cold-pressor stress echocardiography is thus a noninvasive and useful tool for the diagnosis of vasospastic angina.

[Contrast agent improves diagnostic value of dobutamine stress echocardiography]

OBJECTIVES

Suboptimal endocardial definition reduces the diagnostic value of stress echocardiography for coronary artery disease, but intravenous infusion of a left ventricular contrast agent (Albunex) may enhance endocardial border delineation and improve the diagnostic value of dobutamine stress echocardiography.

METHODS

Fifty-six patients, 38 with myocardial infarction, 16 with angina pectoris and two normal subjects, were enrolled in this study. Dobutamine was infused in scalar doses of 5 to 40 micrograms/kg/min. Intravenous infusion of Albunex (0.15 ml/kg) was administered at rest and during peak dobutamine stress during monitoring of the apical four-chamber view. The left ventricle in the apical four-chamber view was divided into six segments and an endocardial delineation score of 0 to 3 (none to excellent visualization) was given to each segment.

RESULTS

Endocardial delineation score was increased after Albunex infusion from 2.0 to 2.3 in the basal-septal, 2.0 to 2.4 in the mid-septal, 1.1 to 1.8 in the apical-septal, 0.7 to 1.2 in the apical-lateral, 0.9 to 1.6 in the mid-lateral, and 1.2 to 1.9 in the basal-lateral segments during peak dobutamine administration. Endocardial border resolution in the lateral wall showed greater improvement than in the septal wall after Albunex infusion. Diagnostic values in the left anterior descending artery territory failed to improve with Albunex infusion (sensitivity 82% to 89%, specificity 94% to 89%, and accuracy 86% to 89%), whereas a higher diagnostic accuracy was noted in the left circumflex artery territory with Albunex compared to without Albunex (sensitivity 63% to 81%, specificity 88% to 98%, and accuracy 80% to 93%, p < 0.05).

CONCLUSIONS

Contrast agent improves the diagnostic accuracy of dobutamine stress echocardiography in the left circumflex artery territory.

Can the proximal isovelocity surface area method calculate stenotic mitral valve area in patients with associated moderate to severe aortic regurgitation? Analysis using low aliasing velocity of 10% of the peak transmitral velocity

To assess the ability of the proximal isovelocity surface area (PISA) method to accurately measure the stenotic mitral valve area (MVA), and to assess whether aortic regurgitation (AR) affects the calculation, we compared the accuracy of the PISA method and the pressure half-time (PHT) method for determining MVA in patients with and without associated AR by using two-dimensional echocardiographic planimetry as a standard. The study population consisted of 45 patients with mitral stenosis. Seventeen of the 45 patients had associated moderate-to-severe AR. The PISA method was performed using low aliasing velocity (AV) of 10% of the peak transmitral velocity, which provided the most accurate estimation of MVA when compared with planimetry. The maximal radius r of the PISA was measured from the orifice to blue-red aliasing interface. Using the PISA method, MVA was calculated as (2pir(2)) x theta / 180 x AV/Vmax, where theta was the inflow angle formed by mitral leaflets, AV was the aliasing velocity (cm/sec), and Vmax was the peak transmitral velocity (cm/sec). MVA by the PISA method correlated well with planimetry both in patients with AR (r = 0.90, P < 0.001, SEE = 0.17 cm(2)) and without AR (r = 0.92, P < 0.001, SEE = 0.16 cm(2)). However, MVA by the PHT method did not correlate as well with planimetry (r = 0.57, P < 0.05, SEE = 0.37 cm(2)) in patients with associated AR, and the PHT method produced a significant overestimation (24%) of MVA obtained by planimetry in these patients. We conclude that the PISA method allows accurate estimation of MVA and is not influenced by AR.

Expression of 15-lipoxygenase-1 is regulated by histone acetylation in human colorectal carcinoma

15-Lipoxygenase-1 (15-LO-1) is expressed at higher levels in human colorectal tumors compared with normal tissue. 15-LO-1 is expressed in cultured human colorectal cells, but only after treatment with sodium butyrate (NaBT), which also stimulates apoptosis and cell differentiation. We examined the regulation of 15-LO-1 in human tissue and the colorectal carcinoma cell lines Caco-2 and SW-480 by treatment with histone deacetylase (HDAC) inhibitors: NaBT, trichostatin A (TSA) and HC toxin. Northern and western analysis showed that expression of 15-LO-1 was up-regulated by these HDAC inhibitors. Furthermore, HDAC inhibitors stimulated promoter activity of the 15-LO-1 gene approximately 12-to 21-fold using the -331/-23 region of the 15-LO-1 promoter, as measured with a luciferase-15-LO-1 promoter-reporter system, suggesting that 15-LO-1 is regulated at the transcriptional level by HDAC inhibitors. Histone proteins in colorectal cells were acetylated after treatment with HDAC inhibitors. Histone acetylation was also measured in human colorectal tissue and a correlation was observed between increased histone acetylation and 15-LO-1 expression. Thus, regulation of 15-LO-1 expression in colorectal tissues appears to occur by a novel and new mechanism associated with histone acetylation. Moreover, these results suggest that 15-LO-1 is a marker that reflects histone acetylation in colorectal carcinoma.

Pancreatoblastoma. Three original cases and review of the literature

PURPOSE

To describe the characteristics of pancreatoblastoma.

MATERIAL AND METHODS

We studied 3 cases of pancretoblastoma and reviewed another 59 cases. Parameters analyzed were tumor site, hemorrhage, capsule formation, necrosis, vascularity, production of alpha-fetoprotein (AFP), cystic changes and calcification.

RESULTS

The diagnostic findings were as follows: pancreatic head origin (24/54, 44%), pancreatic body and tail origin (30/54, 56%), hemorrhage (16/17, 94%), capsule formation (24/26, 92%), necrosis (28/31, 90%), hypervascularity (10/14, 71%), production of AFP (19/28, 68%), cystic changes (11/16, 69%), and calcification (10/21, 48%). All neonatal cases demonstrated cystic changes. Three of them were patients with Beckwith-Wiedmann syndrome. The incidence of capsule formation and calcification was not related to the origin of the tumor.

CONCLUSION

The most common features of pancreatoblastoma are hemorrhage, capsule formation and necrosis.

Metabolic suppression of platelet-type 12-lipoxygenase in human uterine cervix with invasive carcinoma

Several types of lipoxygenases with various functions occur in mammalian cells. Although the presence of 12-lipoxygenase activity has been reported in uterine tissues, neither its type nor its biological functions have yet been established. Moreover, the putative role of uterine 12-lipoxygenase in cervical cancer has not been addressed before. Homogenates of uterine tissues from women without cancer and from patients with invasive cervical carcinoma were incubated with (1-(14)C)-arachidonic acid under various conditions and the labelled reaction products were analyzed both by thin-layer chromatography and by high-pressure liquid chromatography. 12-Lipoxygenase protein was estimated by Western blot using anti-serum against recombinant human platelet-type 12-lipoxygenase. Highest concentrations and activities of 12-lipoxygenase were found in the exocervix. The formation of 12S-hydroxy-5Z,8Z,10E, 14Z-eicosatetraenoic acid (12-HETE) was stimulated by micromolar concentrations of 13S-hydroperoxy-9Z,11E-octadecadienoic acid, suggesting metabolic control of the 12-lipoxygenase activity via the hydroperoxide tone. Immunohistochemical investigation revealed that the enzyme is mainly located in the squamous epithelium, and is of platelet-type. Significantly lower values for the 12-HETE formation were found in samples from patients with invasive cervical carcinoma, whereas the amount of immunochemically detectable 12-lipoxygenase protein was unaltered. At the same time the expression levels of the bcl-2 gene were enhanced. Thus, it is concluded that during carcinogenesis the hydroperoxide-reducing capacity of the uterine cervix tissue is enhanced, possibly mediated by bcl-2 protein, and in turn metabolically suppresses the 12-lipoxygenase activity. Furthermore, the data suggest an anti-carcinogenic action of 12-lipoxygenase in human cervix, in contrast to its reported pro-carcinogenic action in breast cancer.

[Diagnosis of myocardial viability by exercise echocardiography]

This study determined whether the diagnosis of myocardial viability could be established on the basis of the contractile reserve during low level exercise with an ergometer using echocardiography. The study involved 22 patients with transmural old myocardial infarction who underwent exercise echocardiography, followed by coronary intervention after a mean 4 days. Exercise echocardiography was started from 50 W and stepped up by 25 W every 3 min up to a maximum of 150 W. Low level exercise was administered for 1 to 2 min at 50 W. A 16-segment model was used for the left ventricular wall motion, which was evaluated by five-grade scoring, ranging from normokinesis to dyskinesis. If patients showed improvement by one point or more in the score for segments of dyskinesis, akinesis, or severe hypokinesis on the exercise echocardiography, they were considered to have positive viability. The golden standard for the diagnosis of myocardial viability was that wall motion abnormalities before exercise echocardiography should be improved by one point or more after coronary intervention. Before exercise echocardiography, there were 152 segments showing wall motion abnormalities assessed as severe hypokinesis or more. After coronary intervention, improvement of the wall motion by one grade or more was found in 2 of the 18 segments (11%) for dyskinesis, in 38 of the 96 segments (40%) for akinesis, and in 22 of the 38 segments (58%) for severe hypokinesis; improvement for the segments of severe hypokinesis was significantly better than those for dyskinesis and akinesis. Out of 19 segments with akinesis before exercise echocardiography in which wall motion was improved during low level exercise, 16 segments (84%) showed improvement in wall motion after coronary intervention. Out of 77 segments with akinesis before exercise echocardiography in which no change or worsening was seen during low level exercise, 22 segments (29%) showed improved wall motion after coronary intervention. There were 38 segments with severe hypokinesis before exercise echocardiography; out of 12 segments in which wall motion was improved during low level exercise, 7 segments (58%) showed improved wall motion after coronary intervention. Out of 26 segments with severe hypokinesis before exercise echocardiography in which no change or worsening was seen during low level exercise, 11 segments (42%) showed improved wall motion after coronary intervention. Wall motion was improved after coronary intervention in 20 of 25 segments (80%) that showed the biphasic response, in 4 of 7 segments (57%) that showed improvement, in 14 of 43 segments (33%) that showed worsening, in 24 of 77 segments (31%) for no change; the biphasic response showed a significantly higher improvement compared to worsening or no change. If segments in which wall motion was improved during low level exercise are regarded as positive viability segments, occurrences of the sensitivity, specificity and diagnostic accuracy of myocardial viability were 50%, 84%, and 71%, respectively.

Regulation of 12-lipoxygenase in rat intestinal epithelial cells during differentiation and apoptosis induced by sodium butyrate

We evaluated the expression and activity of rat 12-lipoxygenase (LO) in rat intestinal epithelial (RIE) cells during apoptosis and cell differentiation. Sodium butyrate (NaBT) treatment induced wild-type RIE (W-RIE) cells to undergo differentiation and apoptosis. Alkaline phosphatase (ALP) activity, a marker of cell differentiation, and DNA fragmentation, an index of apoptosis, were increased by NaBT treatment. Arachidonic acid was metabolized primarily to 12-hydroxyeicosatetraenoic acid (HETE) suggesting induction of 12-LO activity. In contrast, sense-RIE (S-RIE) cells engineered to overexpress COX-2 were resistant to apoptosis by treatment with 5 mM NaBT and NaBT did not induce 12-LO activity. The upregulation of 12-LO expression by NaBT in W-RIE cells was confirmed at both the transcriptional and translational level but 12-LO was undetectable in S-RIE cells following NaBT treatment. The expression of 12-LO mRNA in W-RIE cells occurs as early as 6 h after treatment and reaches maximum expression at 24 h following treatment. This inducible 12-LO was isolated by RT-PCR and identified as rat "leukocyte-type" 12-LO. The level of 12-LO expression in W-RIE cells was dependent on the concentration of NaBT and appears to reflect the extent of cell differentiation. NDGA, a lipoxygenase inhibitor, attenuated induction of ALP activity by NaBT treatment of W-RIE cells. These observations suggested that 12-LO is regulated by treatment with NaBT and is associated with cell differentiation in rat intestinal epithelial cells.

Epithelioid hemangioendothelioma with marked liver deformity and secondary Budd-Chiari syndrome: pathological and radiological correlation

A case of malignant epithelioid hemangioendothelioma of the liver in a 48-year-old woman with severe portal hypertension and marked deformity of the liver is presented. This woman had a history of mild liver dysfunction since the age of 30 years, and abdominal distention, esophageal varices, splenomegaly and ascites since October 1996. Imaging examinations revealed liver deformity with severe atrophy of the left lobe and the anterior segment of the right lobe. Celiac arteriography showed narrowing and upward deviation of the proper hepatic artery, and occlusion of the left and right anterior hepatic arteries. Since March 1997, hepatic venography showed stenosis in the right hepatic vein truncus. Budd-Chiari syndrome was clinically diagnosed. She died in June 1997. The autopsy disclosed massive tumor embolism in the left and right anterior portal branches, few in the hepatic artery, and occlusion of the left and right anterior hepatic arteries. The extensive tumor embolism resulted in portal hypertension, and atrophy of the left lobe. The anterior segment of the right lobe was probably caused by the occlusion of both the hepatic arteries and the portal veins. The posterior segment of the right lobe, without massive tumor embolism in its portal branch, appeared hypertrophic.

Staining of interleukin-10 predicts clinical outcome in patients with nasopharyngeal carcinoma

BACKGROUND

Interleukin-10 (IL-10) has been implicated as an important modulator of lymphoid cells, and its sequence is homologous to an open reading frame in the Epstein-Barr virus (EBV) genome. Nasopharyngeal carcinoma (NPC) is a representative tumor related to EBV infection.

METHODS

The authors investigated the expression of IL-10 in 21 primary NPCs by using an immunohistochemical approach to examine its prognostic significance.

RESULTS

IL-10 staining was positive in 12 of 21 primary NPCs (57%). There was no association between IL-10 expression and gender, tumor size, the occurrence of lymph node metastases, clinical stage, or recurrence. However, there was a significant difference in overall survival between the negative expression and positive expression of IL-10 (P = 0.0348). Although 87.5% of the IL-10 negative group survived for 5 years, only 15.6% of IL-10 positive patients survived for that length of time by the Kaplan-Meier method. IL-10 expression was significant as an independent prognostic indicator of overall survival by multivariate analysis using the Cox proportional hazards model (odds ratio, 26.64; P = 0.0019).

CONCLUSIONS

The results imply that expression of IL-10 is a prognostic factor in patients with NPC and may prove valuable in selecting patients with NPC who are candidates for aggressive therapy.

Effects of invaginating anastomosis in Kasai hepatic portoenterostomy on resolution of jaundice, and long-term outcome for patients with biliary atresia

BACKGROUND/PURPOSE

This report describes a technique of hepatic portoenterostomy (HPE) to keep sustained bile drainage in biliary atresia patients. In conventional HPE, the medial posterior row of the anastomosis is placed behind the main portal vein. But around both lateral corners where the portal branches enter the liver parenchyma, the anastomosis is placed across and outside of the portal veins. Resultantly, the proximal part of the portal veins become included in anastomosis attaching directly to the dissected area where bile ducts are copious. In a devised procedure designated as invaginating anastomosis (IA), an anastomotic line was placed to invaginate the medial branch of the right portal vein and also placed behind the veins even at their roots. This technique puts all portal branches outside of the anastomosis, preventing cicatricial adhesion at the dissected area with the posterior wall of the veins.

METHODS

The effect of IA was evaluated in terms of resolution of jaundice and long-term outcome compared with conventional anastomosis (CA). Group IA consisted of 20 patients and group CA of 18 patients.

RESULTS

Patients in whom jaundice resolved included 19 (95%) in group IA and 11 (61%) in group CA (P < .05). Reoperation was needed in only one infant in group IA, and in six in CA (P < .05). In patients with reoperation in group CA, the portahepatis was found to be contracted with dense cicatricial tissues. The survival rates for patients with a native liver, calculated excluding those in whom the cause of death was not liver deterioration, was 87% for IA compared with 41% for CA (P < .05). Averaged biliary atresia prognostic index at the last follow-up evaluation was 20.2+/-24.5 for group IA and 62.6+/-29.8 for group CA (P < .001).

CONCLUSION

The invaginating anastomosis in portoenterostomy promised a sustained bile drainage and improved long-term outcome by preventing cicatricial contraction of the portahepatis.

Expression of 15-lipoxygenase-1 in human colorectal cancer

Recently, we reported the induction of reticulocyte type 15-lipoxygenase (15-Lox-1) in a human colorectal carcinoma cell line that had been stimulated by butyrate to undergo apoptosis and cell differentiation (H. Kamitani et al., J. Biol. Chem., 273: 21569-21577, 1998). To determine if 15-Lox-1 is expressed in human colorectal cancer tissue, 21 matched pairs of colorectal tumor and adjacent normal tissue were examined by immunoblot analysis using specific antibodies for human 15-Lox-1, prostaglandin H synthase (also called cyclooxygenase, Cox)-1 and Cox-2. Eighteen of the 21 were found to have 15-Lox-1 in both tumor tissue and matched adjacent normal tissue, with the 15-Lox-1 expression being significantly higher in most of the tumor tissue. The expression of Cox-2 was also elevated in most tumors, whereas Cox-1 was frequently expressed at lower levels in the tumor tissue than in the paired normal tissue. Reverse-phase high-performance liquid chromatography analysis of arachidonate metabolites, formed on incubation of arachidonic acid with a crude enzyme preparation from the colon samples, revealed the formation of 15-hydroxy-5Z,8Z,11Z,13E-eicosatetraenoic acid with a much lower level of 12-hydroxy-5Z,8Z,10E,14Z-eicosatetraenoic acid (15-hydroxy-5Z,8Z,11Z,13E-eicosatetraenoic acid:12-hydroxy-5Z,8Z,10E,14Z-eicosatetraenoic acid, 6.5:1) which also indicate the presence of 15-Lox-1. Furthermore, reverse transcription-PCR with primers specific for human 15-Lox-1 or 15-Lox-2 cDNA indicated that 15-Lox-1 mRNA was present in the colorectal tumors. The sequence of the PCR product was identical to the human 15-Lox-1. Immunohistochemical studies showed 15-Lox-1 localization in the glandular epithelium of human colorectal tumor tissue. These results suggest that 15-Lox-1 is highly expressed in human colorectal cancer epithelial cells and that its expression may have a role in colorectal carcinogenesis.

Cytosolic nuclease activated by caspase-3 and inhibited by DFF-45

To study the intracellular apoptotic signaling pathways, we have established a cell-free system, in which DNA fragmentation of the isolated mouse liver nuclei was induced with lysates from the Fas-activated cells. We have found that the inactive nuclease present in the intact cell cytosol is activated by a caspase-3-like protease and the activated nuclease induces the nucleosomal DNA fragmentation. We attempted the purification of the inactive nuclease from bovine liver cytosol. The partially purified nuclease was activated by recombinant caspase-3, and to a lesser extent by caspase-6. The activated nuclease was able to digest plasmid DNA in addition to induce the DNA fragmentation of nuclei. DFF-45, which is a subunit of heterodimeric protein leading to DNA fragmentation upon its digestion by caspase-3, is found to inhibit the activity of the activated nuclease. These results suggest that the inactive nuclease in cytoplasm is converted to the active form by caspases, and the activated nuclease enters into nucleus to induce the DNA fragmentation. It is suggested that DFF-45 may function as an inhibitory factor of the caspase-sensitive nuclease in vivo.

Carpal tunnel syndrome induced by two types of calcium deposition

Two rare cases of carpal tunnel syndrome caused by calcification in the carpal tunnel are reported. One case involved a tumorous calcification consisting of basic calcium phosphate, and the other involved a diffuse calcification consisting of a mixture of calcium pyrophosphate dihydrate and basic calcium phosphate. These cases suggest that the shape of carpal tunnel calcifications is influenced by the nature of calcifying substance itself, i.e., whether it is heterogenous or homogenous.

[A surgery for an acute case of a ruptured aneurysm associated with idiopathic thrombocytopenic purpura: a case report]

A surgery for an case acute of a ruptured aneurysm with idiopathic thrombocytopenic purpura (ITP) is very rare. We encountered a case of a ruptured basilar artery (BA) superior cerebellar artery (SCA) aneurysm associated with ITP. A successful operation was carried out while the patient was in the acute stage. The patient was a 63-year-old female. She has been suffering from ITP for two years, when she experienced a sudden severe headache and vomitting on May 5, 1995. She was referred to our hospital as a case of subarachnoid hemorrhage estimated to be in group 2 according to the Fisher grade. Her neurological condition caused by the subarachnoid hemorrhage was grade 2 according to Hunt & Kosnik classification, and she was classified according to WFNS as grade 1. The number of platelets was, however, 2.3 x 10(4)/mm3 on admission. Cerebral angiography showed the aneurysm at the bifurcation of BA and SCA. The administration of platelet transfusion, betamethasone and gamma-globulin induced an increase of the number of platelets to 8.7 x 10(4) mm3 just before the operation. Neck clipping for the aneurysm was performed using platelet transfusion via the right pterional approach 25 hours after the onset. No tendency to bleed was recognized during the operation. The number of platelets was kept constantly at the level between 16.9 x 10(4)/mm3 and 22.0 x 10(4)/mm3 during the postoperative course with the administration of betamethasone. The postoperative course was good with no manifestations of delayed ischemic neurological deficits.